Provider Demographics
NPI:1902252117
Name:HUTSON, LAURA (PTA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HUTSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 W GRANADA BLVD
Mailing Address - Street 2:SUITE 4 B 2
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8259
Mailing Address - Country:US
Mailing Address - Phone:386-615-1112
Mailing Address - Fax:
Practice Address - Street 1:1275 W GRANADA BLVD
Practice Address - Street 2:SUITE 4 B 2
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8259
Practice Address - Country:US
Practice Address - Phone:386-615-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26691225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant